Client Information and Office Policy Statement
Informed Consent
Welcome!
I am pleased that you have selected me as your Christian mental health counselor.This is an opportunity to acquaint you with the information relevant to treatment, confidentiality, and office policies. I will answer any questions that you have regarding any of these policies.
Nature of my counseling:
It is my desire to counsel in such a manner that I may help those I counsel to glorify God with their lives, and in doing so, bring honor and glory to the name of the One whom I serve, the Lord Jesus Christ. I intend for my counseling to be a ministry to those who are in need of being strengthened in mind, heart, and soul……desiring to live their life in such a way that they may come to glorify God and enjoy Him now and always. I believe that as people see God’s word and His plan more clearly there will be hope and strength given to them. Some clients will need only a few sessions to see this while others may require months or even years of a counseling relationship. If counseling is successful, you and/or your family should feel that you will be able to face life’s challenges in the future with a God-centered relationship, Biblical principles and direction, and strategies/techniques, without my intervention.
My approach to counseling will center on the following principles of practice:
· To work towards a God-centered relationship with the counselee that is free from being judgmental and/or prejudicial.
· To inform and instruct with Biblical direction that is applicable to the revealed and expressed needs of the counselee.
· To speak the truth in love and with respect for one’s human dignity.
· To make assignments to counselees as needed that will require outside reading and possible activities/exercises that will enhance and encourage understanding of counseling objectives.
· To encourage an appreciation for the importance of commitment.
· To instruct the counselee(s) with strategies/techniques that are significant in problem solving.
· To set goals that are essential for measuring the success of counsel.
· To exhort, exemplify and instill a sense of hope within all counselees.
· To present challenges that motivate counselees towards success in overcoming difficulties.
· To illustrate, describe and implement boundaries that enhance Godly conduct.
· To keep Holy Scripture at the center of all counseling relationships as the key principle from which all rules for faith and practice will be taken.
It should be understood that there may be times in the course of counseling when I will deem it necessary and prudent to refer counselees to other associates and professionals for further advice and direction. Such referrals may or may not be optional for the counselees to continue as a client under my counsel. Such decisions will be made at the discretion of the counselor.
Appointments:
Appointments are usually scheduled for 50 minutes. The practice hours are Tuesday, Wednesday, and Thursday from 9a.m. to 6 p.m. Occasionally, the practice will be open on Mondays. Clients are generally seen weekly or more/less frequently as acuity dictates. You and I will agree on appointment times. You may discontinue treatment at any time, but please discuss any decisions with me. In the event of an emergency, I may be reached at 863-286-9592. If you are unable to reach me, you may call your primary care physician, 911, or the crisis hotline at 863-519-3744.
Confidentiality:
Issues discussed in therapy are important and are generally legally protected as both confidential and “privileged”. However, there are limits to the privilege of confidentiality. These situations include: (1) suspected abuse or neglect of a child, elderly person, or a disabled person, (2) when I believe you are in danger of harming yourself or another person or you are unable to care for yourself, (3) if you report that you intend to physically injure someone, the law requires me to inform that person as well as the legal authorities, (4) if I am ordered by a court to release information as part of a legal involvement in company litigation, etc., (5) when your insurance company is involved, e.g. filing insurance claims, insurance audits, case review or appeals, etc., (6) in natural disasters whereby protected records may become exposed, (7) when otherwise required by law. You may be asked to sign a Release of Information form so that I may speak with other mental health or medical professionals or to family members.
Record Keeping:
A clinical chart is maintained describing your condition, your treatment plan, your progress in treatment, dates of and fees for sessions, and notes describing each therapy session. Your records will not be released without your written consent, unless one of the situations outlined in the Confidentiality section is required. These records are locked and kept on site.
Fees:
It is the policy of Patricia Young to collect payment for services at the time of each appointment. Fee for each visit is $100.00. Fees for other services, such as evaluations, etc. will be discussed individually. It is important to me that financial considerations do not become an obstacle to your accessing services. If the normal fee is problematic for you, please discuss this with me. There will be a $50.00 charge for missed appointments not cancelled 24 hours in advance. If I am a network provider for your insurance you will pay your co-pay fee.
Please check with your insurance company to find out what they will pay for mental health service prior to your visit and they will give you a preauthorization letter/number. If I am a participating provider for your insurance company, your payment will be your co-pay. Please bring your insurance card with you.
If I am not a participating provider for your insurance company, I will be happy to provide a statement for you to send to your company for any reimbursement or deductible fee that they might provide for you.
Payments:
Payment is due at the time of the session unless prior arrangements have been made. Payment should be made in cash, check, or cashier’s check. I do not have credit capabilities. If I am a provider for your insurance company, I will file your claims for you but you will be responsible for deductibles, co-pays, and co-insurance. It is your responsibility to familiarize yourself with your insurance benefits.
Cancellations and Missed Appointments:
You will be billed for missed appointments that are not cancelled 24 hours in advance. You may leave a message 24 hours a day at 863-286-9592. You will be billed $50.00 not just a co-payment. Insurance companies generally do not reimburse for missed appointments.
Complaints:
If there were to be complaints about your treatment, me as a therapist, or any office policy, you have a right to have your complaints heard and resolved in a timely manner. I would appreciate if you would come to me first and we try to settle any problems that may occur. If things cannot be resolved between us, you may contact your insurance carrier, or the state and file a complaint if you so chose.
Consent for Treatment:
In response to my request for counseling services, I have received and reviewed the policies of this office. I understand the expectations, policies, and procedures of Patricia A. Young’s practice. I have been given adequate opportunity to clarify my expectations and otherwise address any questions that I have about these policies and procedures. I agree to accept and abide by the policies and procedures as I obtain counseling services through Patricia A. Young’s practice. I specifically understand and accept my rights and responsibilities related to privacy, scheduling and cancellation of services, and payment of professional fees. I request that counseling services be initiated for me.
Court appearances: You agree not to call me as a witness in any litigation or legal proceedings. Should anyone signing this agreement seek to compel me to provide information in a court proceeding or elsewhere, you agree in advance that you will compensate me, at the rate of $200/hour, for any and all time expended in response to the request for release of information, phone consultation, and preparation of documents. If at any time, I should be called to testify in court, you agree to compensate me $300/hour including preparation of documents, phone consultation, court time, all travel time (portal to portal), plus cost of any legal services which I may employ.
By signing below, you are stating that you have read and understand this 3-page policy statement and you have had your questions answered to your satisfaction.
I, ______, accept, understand, and agree to abide to the contents and terms of this agreement and further, consent to participate in evaluation and/or treatment. I understand that I may withdraw from treatment at any time by talking to you or putting it in writing that I would like to withdraw.
Name of client (please print): ______
Signature: ______
Date: ______
Therapist/Witness: ______
Date: ______
1